Insights Category: Technical Information

The Joint Commission has recently announced a new approach for identifying and evaluating risk levels associated with deficiencies cited during surveys. This new approach, referred to as Survey Analysis for Evaluating Risk (SAFER) matrix, is intended to provide organizations with additional information related to the risk of deficiencies to assist them in prioritizing corrective actions. The SAFER Matrix became effective for psychiatric deemed hospitals on June 6, 2016 and will become effective for the remainder of accredited facilities on January 1, 2017. The matrix will illustrate areas of noncompliance at an aggregate level to show the extent (limited, pattern, widespread) and likelihood to harm (low, moderate, high) that cited deficiencies may cause in the event of a fire. At the end of the survey, the facility will be provided with a SAFER matrix within their Accreditation of Survey Findings Report as shown in the figure at left.

The SAFER Matrix replaces the current scoring methodology. Predetermined Elements of Performance (EPs) such as Categories A and C as well as Direct and Indirect impacts will no longer be utilized. Opportunities for Improvement, such as a single Category C finding, will no longer exist. Further, Measures of Success (MOS), which was previously used as an audit to determine if a certain action is effective and sustained, will not be required for certain Category C findings. Instead, surveyors will perform an on-site evaluation of identified deficiencies to place each EP within the appropriate cell according to the extent and likelihood to harm. Deficiencies of higher risk will still require an Evidence of Standards Compliance (ESC) to be developed and submitted by the facility related to corrective actions. Further, Immediate Threats to Life (ITLs) will be identified within the SAFER Matrix which will require the same follow-up process associated with potential Preliminary Denial of Accreditation.

Contact us if you want to know more about how the new SAFER Matrix will affect your future accreditation process.

The City of Boston Fire Department’s Certificate of Occupancy division is correctly holding building owners accountable to properly maintain their standpipe systems. The checklist at left is being passed out at the BFD fire prevention headquarters, which specifically requires proof of standpipe flow test prior to issuance of any tenant improvement project certificates of occupancy.

NFPA 25 (referenced by the NFPA 14) requires a flow test from the most remote hose connection (typically the roof) for each standpipe zone every 5 years. This requirement is to ensure the water supply still provides the required design pressure at the required flow. There is also a requirement for hydrostatic testing every 5 years for manual standpipe systems and semiautomatic dry standpipe systems. However, manual wet standpipe systems that are part of a combined sprinkler/standpipe systems are not required to be hydrostatically tested.

Having this documentation readily available is critical to ensure that the Certificate of Occupancy for your next TI project is not delayed. Questions? Give us a call and we’d be happy to point you in the right direction.

On July 12th at the American Society of Healthcare Engineers (ASHE) annual conference in Denver, CO George Mills, Director of Engineering for the Joint Commission, announced that the Joint Commission will be eliminating the Plan for Improvement (PFI) portion of the Statement of Conditions (SOC) starting August 1st. See the announcement from ASHE Here. Christopher Lynch. P.E., Principal with Code Red Consultants was in attendance at the presentation by George Mills. The list below summarizes some key information regarding this significant change in the compliance process:

  • Why is the change being made? The change is occurring due to a Centers for Medicare and Medicaid Services rule requiring the correction of known life safety code deficiencies within 60 days of discovering them. It is worthy to note that there is a time based waiver process for items which justifiably take longer to correct.
  • What happens to existing PFIs? Starting August 1st, the Joint Commission will no longer be providing life safety surveyors with access to the e-SOC information or the PFI. The PFI is now an internal tool to help facilities manage their deficiencies. There is no obligation for a facility to provide their known deficiencies to the surveyors when they arrive. Under the previous PFI process, facilities were not cited for deficiencies they proactively reported through the PFI. This is no longer the case and the Joint Commission will be employing a “See it, Cite it” approach.
  • What happens if I receive citations during a survey? The facility will have 60 days to correct identified deficiencies noted during the survey. This will be done through what is called a Survey Plan For Improvement or SPFI.
  • What do I do if I need more than 60 days to correct an item that is cited during a survey? If more than 60 days is needed, the facility has 45 days from the time the finding is made to submit a time limited waiver request through the Joint Commissions Salesforce portal. After submitting the request, the facility will receive a receipt that should be saved as evidence that the request is in the queue. The time limited waiver will be evaluated and approved by CMS.

These changes are substantial and eliminate the protection previously afforded to facilities which proactively identified issues and corrected them on a timeline they created. The elimination of the PFI process will lead many facilities to re-evaluate how they assess their facility for life safety code deficiencies. While there is no longer any protection for proactively identifying issues, the pain facilities will feel if they are identified on survey has been elevated. There is a time based waiver process, however those are evaluated on a case by case basis by CMS and there is no guarantee additional time will be allotted.

Our recommendation is for facilities to evaluate the timing of when they perform life safety evaluations of their facilities. The new system post August 1 will incentivize facilities to have all known deficiencies corrected. We believe this will drive facilities to perform evaluations annually rather than every three years such that the timing and resources needed to correct items can be accommodated before the next Joint Commission inspection. In addition to annual inspections, an additional evaluation in the months preceding an inspection would be advantageous to evaluate compliance of common maintenance items such as fire doors. Mr. Mills made an excellent point during his presentation that it would be wise for facilities to still utilize the PFI tool on the Joint Commission web site to keep the issues visible to hospital leadership to ensure sufficient budgets and resources can be allocated to performing corrective actions.

There will be more information to come on this topic before August 1st, but please feel free to contact us to discuss impacts on your facilities and life safety program.

With the recent adoption of a new state fire code, Massachusetts building owners and property managers need to understand how NFPA 241 applies to their ongoing construction projects. It is the owner’s responsibility to manage the construction fire safety program, whether you are managing a 5,000 SF tenant improvement project or you are developing a new high-rise residential tower. If you have questions about what this means to you, your property, or your project, then you should come join the Boston Fire Department, Boston ISD, Code Red Consultants, and a panel of experts at an upcoming industry event sponsored by the AGC of MA.

Register here for the April 7th event at the Seaport Hotel in Boston, MA.

http://www.agcmass.org/ev_calendar_day.asp?date=4/7/2016&eventid=86

Q: Are separate plumbing fixtures required to be provided for staff and student occupants in educational occupancies?

A: Yes, in accordance with 248 CMR Section 10.10(18)(h)(4):

Q: Are colleges and other higher education buildings considered as “educational” for the purposes of determining plumbing fixture requirements?

A: Yes. For the most part there is general alignment between the occupancy classifications of the building code and the plumbing code in Massachusetts. However, the classification of college buildings will vary between the two:

Plumbing Code: College, University, Higher Education are considered as “Educational” per 248 CMR Section 10.10(18)(h) & Table 1:

Note that the plumbing code classification as “Educational” in colleges is typically reserved for buildings where teaching/lecturing is occurring. For other buildings the plumbing code classifications may be in closer agreement with the building code. For example, a library would be “Assembly”, or a staff office building would be “Office”. In these instances, separate fixtures would not be expected unless teaching/lecture functions were expected.

Building Code: College, University, other Education above the 12th Grade are considered as “Group B, Business” per 780 CMR Section 304.1:

With Massachusetts’ recent adoption of NFPA 1 as part of the new State Fire Code, each construction project a specific NFPA 241 Construction Fire Safety Program. The owner, general contractor(s), and the subcontractors each play an integral role in demonstrating compliance; from proper documentation to collaborative implementation.

NFPA 241 Section 7.2 outlines the owner’s responsibility for fire protection in a building under construction; “The owner shall designate a person who shall be responsible for the fire prevention program and who shall ensure that it is carried out to completion…The fire prevention program manager shall have the authority to enforce the provisions of this and other applicable fire protection standards.” As such, building owners should minimally be responsible for the following:

  1. Assign Fire Protection Program Manager (FPPM) and Alternate
    This individual will be responsible for the enforcement and implementation of the building/campus NFPA 241 Plan and serve as the point of contact for any first responders.
  2. Develop, Manage, and Implement Master Building/Campus NFPA 241 Program
    Provides baseline approach to fire protection and life safety for building. This is used/referenced by current and future construction projects. Depending on complexity, assistance from a fire consultant may be necessary.
  3. Confirm General Contractors and their Subcontractors are developing/implementing their respective Project Level NFPA 241 Plans and Impairment Plans.
  4. Coordinate all impairments on site.
  5. Property Maintenance
  • Fire alarm / Fire Protection / Secondary Power
  • *Smoke Control (most commonly overlooked)
  • Semi-annual testing / Maintenance schedule available on site / Proof of performance and functional criteria are satisfied.
  • Fire Drills / Evacuation Plans

General Contractor’s Role

All GC’s working in the building will be required to issue an independent, Project-Level NFPA 241 Plan for each individual project. Said Plan should reference and incorporate the policies and procedures included in this Program, while speaking to specific fire protection, life safety, and safeguards that are appropriate for the scope of work at hand.

8th Edition 780 CMR

The current Massachusetts State Building Code (8th Edition; also known as 780 CMR) is an amended version of the 2009 International Building Code (IBC). The base 2009 IBC code introduced a new requirement for a fire service access elevator (FSAE) in buildings with an occupied floor more than 120 feet above the lowest level of fire department vehicle access (780 CMR 403.6.1). Massachusetts amended Section 403.6.1 to require a FSAE in buildings more than 70 feet in height above grade plane such that FSAE are required in all hi-rise buildings. In order to serve as the FSAE, an elevator must satisfy the following conditions (780 CMR 3007):

  • The FSAE must serve every floor of the building;
  • The FSAE must be open to a lobby that is:
    • 150 square foot& minimum with an 8-foot minimum dimension on every floor except the street floor.
    • Enclosed by 1-hour smoke barriers with 3/4 –hour doors.
    • Provided with direct access to an exit enclosure.
  • A Class I standpipe hose connection must be provided in the exit enclosure having direct access from the FSAE lobby;
  • FSAE must be continuously monitored at the fire command center; and
  • Normal and standby power must be provided in accordance with 780 CMR Chapters 27 & 30

9th Edition 780 CMR

The 9th Edition 780 CMR is an amended version of the 2015 IBC. For further information about the adoption date of the 9th Edition 780 CMR, applicable codes, and the code adoption process please see Code Red Consultants Blog Post titled Building Code by Chris Lizewski.

The 2015 IBC, and thus 9th Edition 780 CMR, significantly changes the requirements related to FSAEs. The 2015 IBC base code requires that in buildings with an occupied floor more than 120 feet above the lowest level of fire department vehicle access, no fewer than two fire service access elevators, or all elevators, whichever is less, be provided. Additionally, it is important to note the draft amendments for public review do not amend IBC Section 403.6.1 as was done for the 8th Edition 780 CMR. The impact of this code change is twofold in that buildings less than 120 feet in height above the lowest level of fire department vehicle access no longer require a FSAE; however, buildings exceeding this threshold now need two FSAE instead of one. It is important that this code change be considered early in design based on the considerable impact on building core configuration.

In addition to the above code change, the 2015 IBC also introduces the following notable changes:

  • Under the 8th Edition 780 CMR it was required that a Class I standpipe hose connection be provided in the exit enclosure having direct access from the FSAE lobby. This requirement has been updated such that the exit enclosure containing the standpipe must have access to the floor without passing through the fire service access elevator lobby. A change was made to this requirement in order to prevent the passage of smoke from the floor to the FSAE lobby and hoistway when firefighters run hoses from the standpipe to the floor (2015 IBC 3007.9.1).
  • Access to not less than one of the required exits from the floor must be provided without travel through enclosed elevator lobbies (2015 IBC 1016.2)
  • A pictorial symbol designating which elevators are fire service access elevators must be installed on both sides of the hoistway door (2015 IBC 3007.6.5).

Continue to monitor the Code Red Consultants Blog for updates relating to the proposed timeline of the 9th Edition 780 CMR code adoption and any proposed changes to the FSAE.

When is a Special Inspector required?

  • New smoke control systems designed to comply with IBC Section 909 are required to be tested by a Special Inspector (IBC Section 909.18.8.1).
  • Existing smoke control systems where the original design has been altered or where new smoke control equipment is installed may also require a smoke control Special Inspector as determined by the local AHJ.
  • Smoke control systems subject to the requirements of IBC Section 909 include any of the following active or passive systems:

•  Atrium smoke exhaust systems
•  Stairwell pressurization
•  Smokeproof enclosures (ventilated vestibules)
•  Elevator pressurization
•  Zone smoke control systems
•  Underground buildings
•  Use Group I-3 windowless buildings

Who can serve as a Special Inspector?

  • The Special Inspector is required to have expertise in fire protection engineering, mechanical engineering and certification as air balancers (IBC Section 909.18.8.2). It is not uncommon for the Special Inspector to consist of a team of individuals capable of satisfying the requirements for engineering expertise and air balancer certification.

When should the smoke control Special Inspector get involved?

  • It is recommended that the smoke control Special Inspector get involved during the design process. The Special Inspector can provide a review of the design with an eye towards properly integrating the many building components that make up a smoke control design.

When is special inspection testing required to be performed?

  • Duct leakage testing is required to be performed prior to the concealment of ductwork (IBC Section 909.18.1(1))
  • Prior to occupancy and after sufficient completion, testing of pressure differentials, flow measurements, and detection and control verification is required (IBC Section 909.18.8.1(2))

What documentation is required to be prepared by the Special Inspector?

  • The Special Inspector is required to prepare a complete testing report that is reviewed, signed and sealed by a registered design professional. A copy of the final report is required to be filed with the fire code official and a copy is required to be maintained in an approved location within the building (IBC Section 909.18.8.3.1).The report is required to include the following:

•  Identification of all devices by manufacturer
•  Nameplate data
•  Design Values
•  Measured Values

Given the adoption of the new MA State Comprehensive Fire Code earlier this year, ever increasing attention is being paid to construction fire safety in the context of NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations.

Code Red Consultants has been assisting construction and ownership teams in understanding and applying NFPA 241 by means of the development of NFPA 241 Construction Fire Safety Programs; with one such plan being developed for the marquee Millennium Tower Project.

Assisted by this plan, Suffolk Construction has been able to seamlessly transition their existing construction fire safety practices to address the requirements of NFPA 241, while keeping their project and site safe for abutters, constructors, and responding personnel.

While the terminology may be similar, the code does not actually link the occupancy classification of a building or space to the applicable occupant load factor for means of egress design requirements. This is a common misconception we see many designers make that can have a significant impact on the required number or size of exits in a building. When determining the occupant loads for your facility’s egress requirements, it is important to consider the difference between the occupancy classification of the building, and function of the space for the area you are evaluating.

  • Occupancy Classification – based on a building’s use and purpose as determined by Chapter 3 of the International Building Code (IBC). This classification (or several if the facility is a mixed occupancy) is applied throughout all areas of a building.
  • Occupant Load – based on the “function of space”, which is defined independently of the building’s occupancy classification.

While in most cases, the occupancy classification of a building or space aligns with its intended function, this is not always the case. For example, in a typical office building, the office space and any small conference/meeting rooms with less than 50 people will be classified as a Group B Business Occupancy (IBC 303.1, 304.1). However, the function of space for the small conference/meeting rooms align themselves most closely with “assembly without fixed seats, unconcentrated (tables and chairs)” in IBC Table 1004.1.1 and should be loaded with the corresponding occupant load factor accordingly. When calculating the occupant load factor for the conference/meeting rooms, 15 net square feet per occupant should be applied. Often times, we see designers loading these spaces at 100 gross square feet per occupant for “business areas” since they are defined as Group B Occupancies, however this is not technically correct and can have a significant impact on egress design. We often get asked if this same approach would apply to a “breakout” space that, while looking very similar to the conference room described above, differs in that its intended to only act as collaboration space for employees sitting in adjacent cubicles/offices. While the language in the IBC does not directly address this distinction, we often find in practice that the building official is accepting of utilizing an occupant load factor of 100 gross square feet for this type of breakout space if it can be illustrated that it is in-fact a non-simultaneous use with the surrounding offices. This is just one small facet of occupant loads. Stay tuned for Part II which will address the difference between net and gross calculations.